Parents' Experiences of Health Care for Their Children With Cerebral Palsy

Perspectives from clinicians and managers: facilitators and barriers to the uptake of rehabilitation guidance for children with arthrogryposis

PURPOSE

To identify the perceived facilitators and barriers among clinicians and managers about the uptake of expert guidance for rehabilitation of children with arthrogryposis multiplex congenita (AMC) in practice.

METHODS

Qualitative study using individual interviews, guided by the Theoretical Domains Framework (TDF), to explore beliefs and to identify facilitators and barriers to guidance uptake. Interviews were conducted with a convenience sample of 15 clinicians working with children with AMC and four pediatric clinical managers using Microsoft Teams©. Interviews were then transcribed verbatim and analyzed by four independent reviewers using deductive and inductive coding.

RESULTS

The TDF domains of Environmental Context and Resources, Behavioural Regulation, Reinforcement, Beliefs about Consequences, and Social Influences were shared amongst clinicians and clinical managers across North America and Europe as being relevant and influential on the target behaviour of using rehabilitation expert guidance to manage pediatric patients. Among clinicians only, the domain Memory, Attention, and Decision-Making Processes was also found relevant. Among managers only, the domain Social/Professional Role and Identity was found relevant.

CONCLUSIONS

Coupling shared relevant domains amongst clinicians and managers with individual supports and barriers helps to map out what is needed to promote the uptake of rehabilitation guidance at multiple levels.

Prioritized strategies to improve diagnosis and early management of cerebral palsy for both Māori and non-Māori families

AIM

To identify prioritized strategies to support improvements in early health service delivery around the diagnosis and management of cerebral palsy (CP) for both Māori and non-Māori individuals.

METHOD

Using a participatory approach, health care professionals and the parents of children with CP attended co-design workshops on the topic of early diagnosis and management of CP. Health design researchers facilitated two 'discovery' (sharing experiences and ideas) and two 'prototyping' (solution-focused) workshops in Aotearoa, New Zealand. A Māori health service worker co-facilitated workshops for Māori families.

RESULTS

Between 7 and 13 participants (14 health care professionals, 12 parents of children with CP across all functional levels) attended each workshop. The discovery workshops revealed powerful stories about early experiences and needs within clinician-family communication and service provision. The prototyping workshops revealed priorities around communication, and when, what, and how information is provided to families; recommendations were co-created around what should be prioritized within a resource to aid health care navigation.

INTERPRETATION

There is a critical need for improved communication, support, and guidance, as well as education, for families navigating their child with CP through the health care system. Further input from families and health care professionals partnering together will continue to guide strategies to improve health care service delivery using experiences as a mechanism for change.

'There was nothing, just absolute darkness': Understanding the needs of those caring for children and young people with complex neurodisability in a diverse UK context: A qualitative exploration in the ENCOMPASS study

BACKGROUND

Children and young people (CYP) with complex neurodisability experience multiple physical, communication, educational and social challenges, which require complex packages of multidisciplinary care. Part of the holistic care required includes supporting the families and parents/caregivers. The aim of the wider study was to introduce a new programme ('Ubuntu') to parents/caregivers and healthcare professionals (HCPs) in order to test the feasibility and acceptability of the concept and content, with the goal of potential adaptation for the UK in mind. Data collection and analysis uncovered rich data on caregiving journeys, navigation of health services, and perceived service gaps. This paper focuses solely on these topics. Further papers will report on the feasibility and adaptation data.

METHODS

Two rounds of semi-structured interviews were conducted with 12 caregivers of CYP with complex neurodisability and six HCPs from a variety of disciplines, recruited from a community child health service in London Borough of Newham, UK in 2020. The interviews included open-ended questions to explore caregiving journeys, experiences of navigating health services and perceived service gaps. Transcripts were analysed using a data-driven inductive thematic analysis.

RESULTS

Three themes were identified that related to the aim of understanding caregivers' experiences and unmet needs relating to current service provision. These were (1) Caregiver Mental Health, (2) The Information Gap and (3) The Need for Holistic Support. Mental health difficulties were reported, particularly around the period of diagnosis. Priority needs included the provision of clear information about the diagnosis and services offered, opportunities to forge peer support networks and for services across the community to collaborate.

CONCLUSIONS

The delivery of health services for CYP with neurodisability should encompass the broad needs of the family as well as meeting the clinical needs of the CYP.

What do parents want from healthcare services? Reports of parents' experiences with pediatric service delivery for their children with disabilities

PURPOSE

Family-centred service (FCS) is an established approach for delivering services in children's rehabilitation and healthcare. This article describes that parents continue to report mixed experiences with healthcare services for their children, as well as their ideas about what they need and want from these services. These findings will inform the development of an up-to-date measure of Family-Centred Service called Measure of Processes of Care (MPOC 2.0).

METHODS

A qualitative descriptive study was conducted with parents, using focus groups and open-ended interviews. Data were analyzed using inductive content analysis.

RESULTS

Parents want care that is individualized, co-ordinated, easily accessible, and takes into account the entire family dynamic. They want service providers (SPs) to be informed and invested in their child's care, and to provide parents with practical assistance. They also want to be treated with respect, caring and empathy, and to work together with SPs on the care plan. Novel components of care not identified in the original FCS guiding principles include: responsiveness to needs and mental health; effective communication (vs information giving); practical support (in addition to emotional and informational support); and availability and scheduling.

CONCLUSIONS

This article identifies components of healthcare that families find helpful and desirable.

Efficacy of Early Intervention for Infants With Cerebral Palsy in an LMIC: An RCT

OBJECTIVE

To test efficacy of a parent-delivered multidomain early intervention (Learning through Everyday Activities with Parents [LEAP-CP]) for infants with cerebral palsy (CP) compared with equal-dose of health advice (HA), on (1) infant development; and (2) caregiver mental health. It was hypothesized that infants receiving LEAP-CP would have better motor function, and caregivers better mental health.

METHODS

This was a multisite single-blind randomized control trial of infants aged 12 to 40 weeks corrected age (CA) at risk for CP (General Movements or Hammersmith Infant Neurologic Examination). Both LEAP-CP and HA groups received 15 fortnightly home-visits by a peer trainer. LEAP-CP is a multidomain active goal-directed intervention. HA is based on Key Family Practices, World Health Organization. Primary outcomes: (1) infants at 18 months CA: Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT mobility); and (2) caregiver: Depression Anxiety and Stress Scale.

RESULTS

Of eligible infants, 153 of 165 (92.7%) were recruited (86 males, mean age 7.1±2.7 months CA, Gross Motor Function Classification System at 18 m CA: I = 12, II = 25, III = 9, IV = 18, V = 32). Final data were available for 118 (77.1%). Primary (PEDI-CAT mobility mean difference = 0.8 (95% CI -1.9 to 3.6) P = .54) and secondary outcomes were similar between-groups. Modified-Intention-To-Treat analysis on n = 96 infants with confirmed CP showed Gross Motor Function Classification System I and IIs allocated to LEAP-CP had significantly better scores on PEDI-CAT mobility domain (mean difference 4.0 (95% CI = 1.4 to 6.5), P = .003) compared with HA.

CONCLUSIONS

Although there was no overall effect of LEAP-CP compared with dose-matched HA, LEAP-CP lead to superior improvements in motor skills in ambulant children with CP, consistent with what is known about targeted goal-directed training.

Understanding the Perspectives of Paediatric Physicians on Physiotherapy in Paediatric Rehabilitation in Chennai, India: A Qualitative Approach

OBJECTIVES

Children with disabilities may exhibit a multitude of symptoms, and treatment requires a multidisciplinary approach for a satisfactory outcome. Lack of awareness among physicians, lack of referral, and lack of inter-sectoral coordination have hindered paediatric practice in Tamil Nadu, a state in India with a striking childhood disability rate that warrants a timely interdisciplinary approach. However, the perspectives of paediatricians on paediatric physiotherapy are unknown. The aim of the study was to investigate the perspectives of practicing paediatric physicians in Chennai on the role of physiotherapy in paediatrics.

METHODS

For an in-depth exploration, qualitative semi-structured interviews were conducted in person with 10 paediatricians. Audio from the sessions was recorded and transcribed, and data saturation was achieved through iterative analysis.

RESULTS

A grounded theory analysis of the results yielded 5 domains under which the perspectives and expectations of the physicians were described, along with the barriers experienced by patients' parents as explained by their paediatrician. The responses highlighted deficits in awareness, structural support, accessibility and direct communication between physicians and physiotherapists.

CONCLUSIONS

Paediatric physicians have different opinions, and some ignorance persists concerning paediatric physiotherapy. This study warrants a proper structure of the paediatric rehabilitation unit and regular interdisciplinary meetings and focus group discussions to increase access for parents and improve patient outcomes.

The Lived Experience of Parents of Children and Youth With Special Healthcare Needs on Public and Private Insurance: A Phenomenological Study

PURPOSE OF THE STUDY

The number of children and youth with special health care needs (CYSHCN) is steadily growing in the United States. There are significant differences between private and public health plans in terms of cost, adequacy, and parent satisfaction. The purpose of this study was to understand the experiences of parents with CYSHCN enrolled in public and private insurance with or without a nurse care coordinator. This study also sought to understand parents' experience of support.

PRIMARY PRACTICE SETTING

The primary practice setting was participants' choice of location.

METHODOLOGY AND SAMPLE

A qualitative descriptive design was used with 16 parents of children and young adults aged 2 to 21 years. Semistructured interviews were used, and Colaizzi's (1978) eight steps was the selected interpretive method.

RESULTS

Five themes emerged for parents navigating their child's insurance in the presence or absence of a nurse care coordinator: (1) Struggle with Self-Preservation, (2) Abandonment and Isolation, (3) Self-Reliance and Advocacy, (4) Interdependence, and (5) Lifeline. These themes were also dependent on the type of insurance and sources of support available.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Models centered on care coordination can also be used as a mechanism to guide nurse care coordinators in practice. Providing care coordination support could help lessen the caregiver burden especially while navigating public or private insurance. Results highlighted how insurance companies can make potential changes within the health plan infrastructure. Incorporating nursing care coordination activities not only results in health care savings for the health plan but also improved health outcomes for its enrollees.

Stories of restitution: Family experiences of diagnosis and help-seeking for a child with cerebral palsy

BACKGROUND

The experience of living with children with CP is dominated by the voice of the mother while others are rarely reported. Incorporation of the voices of other family members is important for a holistic understanding.

METHODS

Drawing on the philosophical perspectives of pragmatism, generic qualitative methodology, and Frank's narratives, this article highlights how restitution was constructed by 30 family members.

FINDINGS

They constructed restitution by hoping for a cure through either biomedical and/or alternative models of treatment, followed by intransitive and transcendent restitution.

DISCUSSION

This appears to be the first time that restitution has been extended to families living with children with chronic illnesses.

APPLICATION TO PRACTICE

This would mean that paediatric nursing professionals and other health professionals dealing with family members living with children with CP could attend to their stories in an open and focused manner to honour and validate their stories as well as their experiences.

Ankle-foot orthosis adherence in children and adolescents with cerebral palsy: A scoping review

Ankle-foot orthoses (AFOs) are commonly supplied to children with cerebral palsy (CP) to support their gait. However, usage is reported to decrease through adolescence. Because AFOs can allow users to engage in daily activities and develop their independence, a wider understanding of nonadherence is essential to determining the most appropriate ways to support orthotic prescription for children with CP in the future. This scoping review will present the literature that investigates AFO adherence of children or adolescents with CP and identify potential avenues for future research and practice.A literature search was carried out using the EBSCO and Web of Science databases to identify literature that investigates AFO adherence by children with CP through measurement of AFO usage and exploration of factors that may influence that usage. Papers that investigated AFO adherence in children/adolescents with CP, either through usage or factors that could affect usage, were included in this review. Data were synthesized using a charting form developed for this review. In total, three papers were included in this review. Two included assessments of AFO usage and all three included at least anecdotal references to factors that could influence that usage.Variation in usage time was seen across participants in all studies, although the method used to record usage may influence reported usage values. Key factors that could affect usage were observed in four key categories: physical/AFO-related factors, personal factors, social factors, and situational appropriateness. Adherence is a complex subject, and both measurement of usage and factors that influence usage are key components needed to understand how children engage with their AFO. By better understanding the motivators and barriers to adherence, it is possible to better support the provision of AFOs in the future.

Play-based groups for children with cerebral palsy and their parents: A qualitative interview study about the impact on mothers' well-being

BACKGROUND

Cerebral palsy (CP) is the most common childhood physical disability in developed countries. Parents of children with CP experience difficulties that can result in reduced well-being. Health professionals supporting children with CP have been encouraged to focus on parental well-being as this forms part of the child's essential environment. There is a lack of evidence about interventions that holistically support the whole family by providing therapeutic input for the child and support for parents. This study aimed to explore parents' experiences of play-based groups for children with CP and their parents, with a focus on the groups' impact on parents' well-being.

METHODS

Parents of children with CP who had attended play-based groups in the year prior were recruited for this qualitative study. Semi-structured interviews were conducted, audio-recorded and transcribed verbatim. Participants' demographic characteristics were collected as contextual information. Data were analysed using an inductive thematic approach.

RESULTS

Ten mothers were interviewed. Overall, mothers had positive experiences of the groups and perceived them as an important influence on their well-being. Four themes described mothers' experiences of the groups and the subsequent impact on their well-being: (1) practical support, (2) connecting with others, (3) transitioning journeys and (4) different motivators, different experiences. Numerous factors influenced mothers' experiences of attending the groups and the subsequent impact on their well-being. This included mothers' individual experiences of having a child with CP.

CONCLUSIONS

Interventions combining practical and social support for the whole family can have a positive impact on the well-being of mothers of children with CP. Care should be taken to provide individualised support for each family. There is no 'one-size-fits-all' approach, and a package of care can provide multiple services that meet the varying needs of mothers and their children with CP.

Mothers' experience of having a child with cerebral palsy. A systematic review

AIM

To explore, synthesise and present findings of qualitative studies describing the experiences of mothers raising a child with cerebral palsy.

DESIGN

A systematic literature review of the qualitative evidence.

METHODS

A systematic search for qualitative studies published in the following databases: CINAHL (EBSCO), Medline via OVID, SCOPUS, and Google Scholar. The authors independently assessed eligibility, appraised methodological quality using the Critical Appraisal Skills Program tool for qualitative Research (CASP). An inductive thematic analysis method was adopted to synthesise major findings and to construct core concepts and themes.

RESULTS

Five overarching themes reflecting the experiences and perceptions of mothers raising and caring for a child with cerebral palsy are developed: 1) adapting and making sacrifices; 2) guilt and cultural blame; 3) social stigma and marginalisation; 4) physical, environmental, and financial challenges and 5) healthcare experiences.

Parental Stress and Bringing up a Child with Cerebral Palsy: A Foreign Studies Review

<p style="text-align: justify;">Raising a child with cerebral palsy contains difficult stress, which negatively affects everyone who is involved in this process. In native psychology, this problem is described by I.U. Levchenko, V.V. Tkacheva, V.A. Vishnevsky, T.N. Volkovskaya. However, there is a lack of research on stress for people, who are raising a child with cerebral palsy. The purpose of this review is to learn about foreign studies on stress for people, who are raising children with cerebral palsy. The article describes R. Abidin's current leading model for parental stress. The connection between raising a child with cerebral palsy and parental stress is considered based on R. Abidin's model. Particularly, the results of studies describe specific aspects of parental stress: lack of knowledge on special child care, not an equal assignment for parental responsibilities, separation anxiety, parent's health problems, social isolation, and guilt. Based on the analysis, we can conclude that raising a child with cerebral palsy is associated with a higher level of stress than raising children without disabilities. This information can be used both in similar studies for a domestic sample and in active programs to reduce parental stress.</p>

Electronic health record and patterns of care for children with cerebral palsy

AIM

To characterize the patterns of care of children with cerebral palsy (CP) in a tertiary healthcare system.

METHOD

Electronic health record data from 2009 to 2019 were extracted for children with CP. Machine learning hierarchical clustering was used to identify clusters of care. The ratio of in-person to care coordination visits was calculated for each specialty.

RESULTS

The sample included 6369 children with CP (55.7% males, 44.3% females, 76.2% white, 94.7% non-Hispanic; with a mean age of 8y 2mo [SD 5y 10mo; range 0-21y; median 7y 1mo]) at the time of diagnosis. A total of 3.7 million in-person visits and care coordination notes were identified across 34 specialties. The duration of care averaged 5 years 5 months with five specialty interactions and 21.8 in-person visits per year per child. Seven clusters of care were identified, including: musculoskeletal and function; neurological; high-frequency/urgent care services; procedures; comorbid diagnoses; development and behavioral; and primary care. Network analysis showed shared membership among several clusters.

INTERPRETATION

Coordination of care is a central element for children with CP. Medical informatics, machine learning, and big data approaches provide unique insights into care delivery to inform approaches to improve outcomes for children with CP. What this paper adds Seven primary clusters of care were identified: musculoskeletal and function; neurological; high-frequency/urgent care services; procedures; comorbid diagnoses; development and behavioral; and primary care. The in-person to care coordination visit ratio was 1:5 overall for healthcare encounters. Most interactions with care teams occur outside of in-person visits. The ratio of in-person to care coordination activities differ by specialty.

Caregivers' Feeding Experiences and Support of Their Child with Cerebral Palsy

Feeding difficulties are often reported in children with cerebral palsy (CP) and are associated with caregiver stress. This study explored the feeding experiences and support of caregivers with children who have CP. A qualitative approach was used where semi-structured telephone interviews were conducted and audio recorded. Thematic analysis was used to code and analyse the transcribed interview data from the eleven mothers that participated. Four major themes were identified from the data: Child-centred world, Making decisions, Knowing their child, and Seeking and receiving support. Caregivers knew their child's unique needs and made daily decisions around feeding based upon the child's feedback and changing condition. Family support was viewed as important, although the caregivers still reported feeling stressed. Health professional support varied from "amazing" to "frustrating", which contributed to the caregivers' stress. However, no single support strategy was appropriate as their needs or preferences varied. It is recommended that health professionals take an individualised partnership approach with caregivers and their child, with particular attention to those caregivers who lack a friend or family support and those who are physically isolated.

Occupational balance and quality of life in mothers of children with cerebral palsy

Introduction

Occupational balance (OB) is an important concept in occupational therapy and is considered as an essential component of health and well-being. The aim of this study was to show differences in OB and quality of life (QoL) between mothers of children with cerebral palsy (CP) and typically developing children.

Methods

Thirty-six mothers of children with CP and 36 mothers of typically developing children participated in the study. The mothers’ OB was evaluated using the Turkish Occupational Balance Questionnaire-11 (OBQ11-T), and their QoL was evaluated with the Nottingham Health Profile (NHP).

Results

The OBQ11-T, total score, and the item ‘balance between obligatory and voluntary occupations’ score differed significantly between the groups ( p < 0.05). There were also significant differences in NHP’s aspects of emotional reaction, social isolation, and sleep scores between the groups ( p < 0.05). A negative correlation was detected between OBQ11-T total and NHP total scores in mothers of children with CP ( p < 0.01).

Conclusion

This study demonstrates that occupational therapists should pay attention to balance between obligatory and voluntary occupations to promote occupational balance. Also, QoL in mothers of children with CP should be evaluated. Therefore, occupational therapists should implement interventions to increase them when necessary for mothers of children with CP.

The Construction of "Self" in Individuals With Congenital Facial Palsy

Congenital facial palsy is a rare medical condition that causes paralysis of the facial muscles, lack of facial expression, and an unusual appearance. Findings from developmental psychology suggest that the face plays a central role in the construction of self. Semi-structured interviews were conducted with 14 adults born with congenital facial palsy. Participant's constructions of self across the life span were explored and a grounded theory of this process was constructed. Theoretical sampling was conducted with two parents of children born with the condition. All participants reported "struggling to make connections," "experiencing invalidation," and "struggling to regulate affect," which lead to "constructing a defective sense of self." Alternatively, "making validating connections" facilitated the process of "constructing a validated sense of self." This study provides insight into the unique social and emotional challenges often experienced by those born with congenital facial palsy and highlights the need for early psychosocial intervention.

Living life with cerebral palsy? A description of the social safety nets for individuals with cerebral palsy in the Nordic countries

Aims:

This report reviews major laws, acts and regulations of social benefits and services for individuals with disabilities, focusing on cerebral palsy in the five Nordic countries. It summarizes the available benefits and services and the re-application process and provides comparative analyses among the countries.

Methods:

Published reports, articles and relevant government and municipal websites were reviewed for each respective country and used to compile an overview and comparison between the countries.

Results:

In the Nordic countries, there are a number of laws and regulations in place to support individuals with cerebral palsy and their families. In addition, there are numerous social benefits available for which individuals with disabilities can apply. Although there are national differences, the similarities across the five countries regarding laws, social benefits offered for individuals with cerebral palsy and the application processes are clear. However, the application processes seem cumbersome and, at times, redundant. Physicians and other healthcare specialists repeatedly need to write ‘medical certificates’ describing the diagnosis and its consequences for a disability that is chronic and lifelong.

Conclusions:

Participation in society for individuals with cerebral palsy disabilities can be enabled by social benefits. By extension, social benefits may indirectly have implications for public health in individuals with disabilities. Although the lives of individuals with cerebral palsy – as with others – can improve in certain areas, the need for social benefits will generally increase, not decrease, over time. Although it is clearly important to have checks and balances that prevent system misuse, it might be worthwhile from a cost-benefit perspective to investigate whether the current systems could be improved to better manage time and resources and avoid emotional distress by streamlining the application process.

When Facing Hopeful and Hopeless Experiences: Using Snyder's Hope Theory to Understand Parents' Caregiving Experiences for Their Medically Complex Child

INTRODUCTION

An emerging subpopulation within pediatric chronic illness is children living with complex chronic conditions. Managing a child's complex chronic conditions can be emotionally taxing for parents. Many parents regard hope as a "life-sustaining and essential" process for them.

METHOD

We used the central concepts within Snyder's hope theory to guide our directed content analysis of parents' interviews about their hopeful and hopeless experiences. Our sample consisted of primarily Christian married mothers.

RESULTS

We found themes within each concept of Snyder's hope theory that clarifies the social and communicative processes that facilitate more hopeful thinking for parents.

DISCUSSION

Understanding how individuals communicate or enact hopeful thinking is an important contributor to performing hope in social settings like hospitals and nonprofit organizations (Ronald McDonald House) that support parents with medically complex children. Our findings indicate that messages should help parents identify care solutions, offer words of encouragement, and help parents create life goals that maintain a child's quality of life.

Income trajectories of families raising a child with a neurodisability

PURPOSE

To examine household income trajectories of children with and without neurodisability over a period of 6 years.

METHOD

We used four cycles of the Canadian National Longitudinal Survey of Children and Youth, a longitudinal study of the development and well-being of Canadian children from birth into adulthood.

RESULTS

While household income increased over time for both groups, families of children with neurodisability had consistently lower household income compared to families of children without neurodisability even after controlling for child and family socio-demographic characteristics. The presence of an interaction effect between parent work status and child with neurodisability at baseline indicated that among children whose parent(s) were not working at baseline, household incomes did not differ between children with and without neurodisability.

CONCLUSIONS

The association between child with neurodisability and lower household income may not hold for all types of parents', working status is an important consideration.Implications for RehabilitationFindings support the health selection hypothesis that health status shapes diverging economic conditions over time: children with a ND have lower household incomes than children without a ND child across all waves of the Canadian National Longitudinal Survey of Youth.Income gaps did not increase or decrease over time; rehabilitation services and policies must consider the lower average incomes associated with raising a child with a ND.Social assistance support likely plays a key role in closing the gap, especially for non-working families.

Quality of Life and Health Services Utilization for Spanish Children With Cerebral Palsy

PURPOSE

To examine the health-related quality of life of children with cerebral palsy and its relationship with their use of health resources, taking into account sociodemographic factors concerning the family context.

DESIGN AND METHODS

Cross-sectional study of children with cerebral palsy in Granada (Spain). Quality of life was evaluated with PedsQL questionnaire.

RESULTS

A total of 75 children were analysed (mean age 7.41 years; SD 4.37; 50.7% male). They made an average of 22.80 visits (SD 12.43) per year; greater use was made of resources by children who had been diagnosed with cerebral palsy for <45 months (36.00 vs. 26.93 visits per year, p < 0.0001). Older children suffered more fatigue and pain. Children aged 2-4 years who presented with fatigue had more hospitalizations (r = -0.35; p = 0.20), whereas those >4 years who had a higher quality of life for daily activities had made more visits to hospital A&E (r = 0.35, p = 0.043). Among the children studied, there was no significant association between HRQOL and the parents' education or occupation.

CONCLUSION

These findings highlight variables that may influence children's quality of life and their use of health resources, identifying certain profiles of children who might need individualized interventions.

PRACTICE IMPLICATIONS

These findings could inform services provided by paediatric nurses to children with cerebral palsy, to individualize interventions and improve patient centred care.

Disabled and immigrant, a double minority challenge: a qualitative study about the experiences of immigrant parents of children with disabilities navigating health and rehabilitation services in Norway

BACKGROUND

Immigrants and their Norwegian-born children make up approximately 18% of the total population in Norway. While several studies have been conducted on immigrants' utilization of healthcare services, immigrant families are systematically underrepresented in international studies of children with disabilities. By focusing on experiences of immigrant parents of children with disabilities navigating health and rehabilitation services in Norway, this study generated knowledge of how accessible and tailored the services were from their point of view.

METHODS

This study took a qualitative approach, using semi-structured interviews to explore the experiences of immigrant parents of children with disabilities from non-Western countries. The interviews were transcribed, coded, and analyzed via an inductive thematic analytic approach.

RESULTS

The findings show how the "immigrant experience" influenced the way the parents looked at, experienced, and even praised the services. The parents appreciated the follow-up services provided by the pediatric rehabilitation centers, which they experienced as predictable and well-organized. While navigating the services, they experienced several challenges, including the need for information, support, and timely help. They felt exhausted because of years of struggle in the healthcare system to access the help and services they needed. They expressed how this struggle had affected their own health. The feeling of being treated differently from the majority was another challenge they experienced while navigating the services. The findings also show how parents' experiences of communication with healthcare providers were influenced not only by their own language and communication skills but also by the healthcare providers' intercultural communication skills and dominant organizational culture.

CONCLUSIONS

The parents' experiences show that there is still a gap between the public ideal of equal healthcare services and the reality of the everyday lives of immigrant families of children with disabilities. By exploring immigrant parents' experiences, this study highlights the importance of mobilization at both the individual and systemic levels to fill the current gap and provide tailored and accessible services to the entire population.

Longitudinal effects of caregiving on parental well-being: the example of Rett syndrome, a severe neurological disorder

Little longitudinal research has examined parental well-being in those with a child with specific genetic developmental disorder although the associated severe neurological impairments and multiple physical comorbidities likely place substantial burden of caregiving on the parent. We aimed to examine longitudinally the well-being of parents of individuals included in the Australian Rett Syndrome Database over the period from 2002 to 2011 using the Short Form 12 Health Survey. Residential remoteness, the child being a teenager at baseline, having frequent sleep disturbances or behavioural problems, and the type of MECP2 gene mutation were each associated with later poorer parental physical well-being scores. Being a single parent or on a low income was also associated with later poorer physical well-being, while the child having enteral feeding was associated with later poorer emotional well-being. Both the physical and emotional well-being of the parent improved if the child was living in out-of-home care. Our findings suggest that some opportunities do exist for clinicians to help optimise parental well-being. Being alert to the possibility and need for management of a child's sleep or emotional disturbance is important as is awareness of the additional likely parental burden as the child moves through adolescence into early adulthood and their need for additional support at that time. However, the findings also highlight the complex nature of parental well-being over time in parents of children with a severe neurological disorder and how they may be affected by a range of inter-related family and child factors.

Unsung heroes, flying blind-A metasynthesis of parents' experiences of caring for children with special health-care needs at home

AIMS AND OBJECTIVES

To aggregate, synthesise and interpret qualitative research studies of parents' experiences of caring for a child with special health-care needs at home.

BACKGROUND

Advances in the field of medical and nursing science have ensured better survival rates for children with chronic illnesses. Many of these children have significant special health-care needs. Today parents assume a caregiver role, undertaking tasks previously provided by nurses in hospitals. As the complexity of care delivered by parents continues to develop, synthesised knowledge can provide an evidence base that will support and guide nurses when caring for these families.

DESIGN

Metasynthesis.

METHODS

Based upon a systematic search protocol, a structured literature search, covering the years 2003-2016, was conducted in five electronic databases. Ten studies were included and appraised using the Critical Appraisal Skills Program assessment tool. A metasummary and a metasynthesis were undertaken guided by the metasynthesis methodology as described by Sandelowski and Barroso (Handbook for synthesizing qualitative research. New York, NY: Springer, 2007).

RESULTS

The results were interpreted and integrated under the overarching theme "unsung heroes, flying blind," supported by eight elucidating categories that illustrate aspects of the parents' life world.

CONCLUSIONS

The enormous burden of care can weaken the parents' will to carry on and result in a decreased ability to provide care. This can have an impact on the parents' health, family functioning and the sick child's potential health outcomes. Nurses are in a unique position to help these families and should be better prepared for the role.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of how parents of children with special health-care needs experience their daily lives can promote trust in nurses and guide them in their efforts to support families with children living with chronic illness.

Themes, Theories, and Models

Although theory building is often described as the ultimate goal of qualitative research, an examination of articles in Qualitative Health Research ( QHR) shows that themes are actually the typical format for reporting results. In addition, articles that rely on themes often present low-level theories in the form of models that connect these themes. Because models have received less attention than either themes or theories, this article concentrates on summarizing four different kinds of models: hierarchies, timelines, processes, and cycles. In each of these cases, it presents both a general illustration of such a model and a realistic example from a published article in QHR. It concludes with a call for greater recognition of the role that models play in capturing the results of qualitative research.

Changes in the Content of Pediatric Physical Therapy for Infants: A Quantitative, Observational Study

AIMS

The aim of our observational longitudinal study is to evaluate changes over time in standard pediatric physical therapy (PPT) for infants at risk of neurodevelopmental disorders.

METHODS

Treatment sessions in two time periods (2003-2005 [n = 22] and 2008-2014 [n = 16]) were video recorded and analyzed quantitatively in five categories: neuromotor actions, educational actions, communication, position, and situation of treatment session. Differences in percentages of time spent on therapeutic actions between periods were tested with Mann-Whitney U and Hodges Lehmann's tests.

RESULTS

No significant changes appeared in the main categories of neuromotor actions. Time spent on not-specified educational actions toward caregivers (median from 99% to 81%, p = .042) and not-specified communication (median from 72% to 52%, p = .002) decreased. Consequently, time spent on specific educational actions (caregiver training and coaching; median from 1% to 19%, p = .042) and specific communication (information exchange, instruct, provide feedback; median from 21% to 38%, p = .007) increased. Infant position changed only minimally: time spent on transitions-that is, change of position-decreased slightly over time (median from 7% to 6%, p = .042). Situation of treatment session did not change significantly over time.

CONCLUSIONS

Neuromotor actions in PPT remained largely stable over time. Specific educational actions and communication increased, indicating larger family involvement during treatment sessions.

The participation of parents of disabled children and young people in health and social care decisions

BACKGROUND

There is widespread acceptance that parents should be fully involved in decisions about their son or daughter's health and social care. This is reflected in partnership models of practice as well as local and national policy across the United Kingdom. Previous research indicates that parents' experiences of decision making with professionals are mixed.

AIM

The research reported here aimed to explore parents' experiences of participating in decisions made with professionals about their disabled son or daughter's care.

DESIGN

This research used mixed methods including survey methodology and qualitative in depth interviews.

SETTING AND PARTICIPANTS

The research was conducted in one Trust in Northern Ireland. Participants were 77 parents of children and young people with a range of impairments aged between 3 and 28 years.

RESULTS

Three themes emerged from the data: taking the lead, not knowing, and getting the balance right. Parents wanted to be involved in all aspects of decision making. Although parents reported many examples of good practice, there were also times when they did not feel listened to or did not have enough information to inform decisions.

DISCUSSION AND CONCLUSION

Parents in this research recounted positive as well as negative experiences. Parents took on a protective role when decisions were made about their son or daughter and at times, reported the need to "fight" for their child. The provision of information remains problematic for these families, and at times, this created a barrier to parents' participation in decision making. Partnership approaches to care that recognize parents' expertise are particularly important to parents when decisions are made with professionals.

Parents' Experiences and Perceptions when Classifying their Children with Cerebral Palsy: Recommendations for Service Providers

AIMS

This study investigated the experiences and perceptions of parents of children with cerebral palsy (CP) when classifying their children using the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), and the Communication Function Classification System (CFCS). The second aim was to collate parents' recommendations for service providers on how to interact and communicate with families.

METHODS

A purposive sample of seven parents participating in the On Track study was recruited. Semi-structured interviews were conducted orally and were audiotaped, transcribed, and coded openly. A descriptive interpretive approach within a pragmatic perspective was used during analysis.

RESULTS

Seven themes encompassing parents' experiences and perspectives reflect a process of increased understanding when classifying their children, with perceptions of utility evident throughout this process. Six recommendations for service providers emerged, including making the child a priority and being a dependable resource.

CONCLUSIONS

Knowledge of parents' experiences when using the GMFCS, MACS, and CFCS can provide useful insight for service providers collaborating with parents to classify function in children with CP. Using the recommendations from these parents can facilitate family-provider collaboration for goal setting and intervention planning.

Family-oriented services in pediatric rehabilitation: a scoping review and framework to promote parent and family wellness

Family-oriented services are not as common as one would expect, given the widespread endorsement of family-centred care, the role of parents in supporting optimal child outcomes, and legislation and literature indicating that parent outcomes are important in their own right. There are no published service delivery frameworks describing the scope of services that could be delivered to promote parent and family wellness. A scoping review was conducted to identify types of family-oriented services for parents of children with physical disabilities and/or intellectual impairments. This information was then synthesized into a conceptual framework of services to inform service selection and design. A scoping review of the recent literature was performed to capture descriptions of services targeting parents/families of children with physical disabilities and/or intellectual impairments, published in a six-year period (2009 to 2014). Six databases were searched and 557 retrieved articles were screened using inclusion and exclusion criteria. Thirty six relevant articles were identified. Based on descriptions of services in these articles, along with seminal articles describing the nature of desirable services, we propose a needs-based and capacity-enhancing framework outlining a continuum of family-oriented services for parents of children with disabilities. The framework includes six types of services to meet parent/family needs, organized as a continuum from fundamental information/education services, to those supporting parents to deliver services to meet their child's needs, to a variety of services addressing parents' own needs (support groups, psychosocial services and service coordination). The framework provides pediatric rehabilitation service organizations with a way to consider different possible family-oriented services. Implications include the particular importance of providing information resources, support groups and psychosocial services to meet parents' needs, enhance capacity and promote family wellness. There is also an opportunity to provide composite parent-child services to address the needs of both parents and children.

Medical service use in children with cerebral palsy: The role of child and family factors characteristics

AIM

The aim of the study was to investigate the patterns of medical service use in children with cerebral palsy (CP), taking into account child and family characteristics.

METHODS

Nine hundred and one parents and carers of children registered with the Victorian CP Register were invited to complete a survey. Participants were asked about their child's appointments with general practitioners and public and private paediatric medical specialists over the preceding 12 months. Information on family characteristics and finances was also collected. Data on CP severity and complexity were extracted from the CP Register.

RESULTS

Three hundred and fifty parents and carers (39%) participated. Of these, 83% reported that their child had ≥1 appointment with a general practitioner over the preceding 12 months, while 84% had ≥1 appointment with a public or private paediatric medical specialist. Overall, 58% of children saw 2-5 different paediatric medical specialists, while 9% had appointments with ≥6 clinicians. Children with severe and complex CP were more likely to have had ≥1 appointment with a publically funded paediatric medical specialist and had seen a greater number of different clinicians over the study period. Family characteristics were not associated with service use.

CONCLUSIONS

Children with CP are managed by a number of paediatric medical specialists, and they continue to see a range of specialists throughout adolescence. In Victoria, differences in service use are not based on family characteristics; instead the highest service users are those with severe and complex CP. For this group, care co-ordination and information sharing between treating clinicians are important, if gaps in care are to be avoided.

Communication and context are important to Indigenous children with physical disability and their carers at a community-based physiotherapy service: a qualitative study

QUESTION

What are the experiences of Indigenous children with physical disability and their carers of their community-based physiotherapy service? What factors influence their experiences of the physiotherapy service and how could the service be improved?

DESIGN

A qualitative study using in-depth, semi-structured open-ended interviews consistent with the researchers' interpretivist perspectives and ethical principles of Indigenous health research. Interviews were audio recorded, transcribed and coded for themes with qualitative research software using inductive analysis. The interviews were then checked for transcription accuracy and the themes were confirmed with the participants.

PARTICIPANTS

Nine parents and foster carers of children with physical disability aged 0 to 21 years, five children and youth with physical disability aged 8 to 21 years.

RESULTS

The data generated three themes, which informed practice recommendations: carers of children with physical disability experience increased demands and complexity in their lives; relationships involving caring, consistency and communication are important to consumers using the physiotherapy service; and being Indigenous influences consumers' experiences in ways that may not be obvious to non-Indigenous service providers. The issue of communication underpinned the participants' experiences throughout these themes.

CONCLUSION

The research highlighted the importance of effective communication, developing relationships, viewing the child wholistically and recognising the influence of being Indigenous on clients' healthcare needs and experiences. The results suggested that community-based physiotherapists adopt a family/person-centred, context-specific approach when working with Indigenous children with a physical disability and their carers.

Improving physiotherapy services to Indigenous children with physical disability: Are client perspectives missed in the continuous quality improvement approach?

OBJECTIVE

To compare the outcomes of two cycles of continuous quality improvement (CQI) at a paediatric physiotherapy service with findings from interviews with clients and their carers using the service.

DESIGN

Case study based at one paediatric physiotherapy service

SETTING

Community-based paediatric allied health service in Northern Australia.

PARTICIPANTS

Forty-nine clinical records and four staff at physiotherapy service, five Indigenous children with physical disability aged 8-21 years, and nine carers of Indigenous children aged 0-21 years (current or previous clients).

INTERVENTIONS

The CQI process based on the Audit and Best Practice for Chronic Disease involved a clinical audit; a workshop where clinicians assessed their health care systems, identified weaknesses and strengths, and developed goals and strategies for improvement; and reassessment through a second audit and workshop. Twelve open-ended, in-depth interviews were conducted with previous or current clients selected through purposive and theoretical sampling. CQI and interview results were then compared.

MAIN OUTCOME MEASURE

Comparison of findings from the two studies

RESULTS

Both CQI and interview results highlighted service delivery flexibility and therapists' knowledge, support and advocacy as service strengths, and lack of resources and a child-friendly office environment as weaknesses. However, the CQI results reported better communication and client input into the service than the interview results.

CONCLUSION

The CQI process, while demonstrating improvements in clinical and organisational aspects of the service, did not always reflect or address the primary concerns of Indigenous clients and underlined the importance of including clients in the CQI process.